December 2009 Archives

Today's New York Times Science Section has a ridiculous article titled, 'Sorry Vegans, Brussels Sprouts Like to Live.' While I am not vegan, and I dislike brussels sprouts, this article deserves some of my scorn.

The gist of this thought piece is that plants do what they can to survive, that they in some sense 'want' to live and therefore there really isn't a substantive difference between eating a head of cabbage or a head of a pig.

One of the most basic features of all life- from the simplest single celled amoeba to the most complex mammal- is the instinct to survive. So it shouldn't exactly be news to anyone, be they herbivore or carcass chewer, that plants- no less than any member of the tree of life, do whatever they can to survive when threatened.

The article gives some fairly neat-o examples of this: almost instant chemical reactions by plants in response to insects chewing or the production of tumor like cells to rid themselves of larvae. Cool. And irrelevant to the questions arisen by dietary choices.

The subset of vegetarians and vegans who base our food choices on ethical principles are, I feel safe in saying, universally aware that plants are alive, and hence attempt to stay alive. Given that photosynthesis isn't an option for us, we draw the line at the Kingdom level (remember high school biology? Kingdom Phylum Class Order Genus Species- the basic hierarchy of taxonomy King Phillip Came Over From Greece Stoned?) 

We are well aware that plants are alive and that they want to stay alive. We also know that chemical changes are not the same thing as thought or feeling. Responding to stimuli isn't equal to sentience. Simply, we aren't vegetarians because we can't stomach any form of killing, just the killing (and torture, warehousing, and other forms of mistreatment involved in the meat industry) of animals.

Hell, if the standard is not to kill any living thing, well we couldn't wash our hands lest the millions of staphylococcus aureus critters be destroyed. We couldn't take antibiotics. We couldn't brush our teeth, sterilize surgical instruments or pretty much do anything.  

All life seeks to live- to persist and usually to reproduce. It is our prime directive, our most basic of instincts. Vegetarians and vegans do not labor under the illusion the food we eat wasn't once alive. In short, we are not as delusional, misinformed or just downright silly as this article is.

Happy Holidaze everyone. Time to make the Tofukey. 

Busy news day: four HIV stories percolating in the media right now, covering everything from koala bears to microbicides; from drugs and suicide to yet another premature loss of an important activist.

First there is the death of Dennis deLeon. Dennis was the president of the Latino Commission on AIDS, a lawyer in the Koch administration and the Civil Rights Commissioner when David Dinkins was the Mayor of New York City. Under his leadership, the LCOA grew from an organization with 2 employees, to a nationally prominent force, working with groups across the US and employing 45. I will leave it to people who knew him better to eulogize Dennis. I will say that the fights against AIDS and for civil rights lost a lion.

The next story is a candidate for the worst headline ever: 'Koalas in Australia Dying of AIDS...'. Koalas get AIDS? As the kids say these days, WTF? Reading the story you find out that Koalas are suffering from the twin threats of habitat decline and a viral infection that destroys their immune system. The viral infection is called KoRV, or Koala associated Retrovirus. KoRV is not related to HIV, but has some similar properties. It does not cause AIDS, but a similar disease called KIDS, or Koala Immune Deficiency Syndrome.  KoRV acts like a typical retrovirus. It is an endogenous retrovirus, meaning it has successfully incorporated itself into the Koala genome and is passed from mother to infant. It is thought that virtually all Koalas carry the virus, but it only sickens some. When it does sicken an animal, it is much more aggressive than HIV.

I don't know much about marsupial retroviruses. What I can say is the headline of this article is misleading (they get KIDS not AIDS). All headlines seek to draw a reader's attention, but when they do so by misleading it is simply bad journalism. As Eric Cartman once said, 'I am not just sure, I am HIV positive.'

Next up: yet another setback in the search for an effective vaginal microbicide. Researchers studying PRO 20000 reported results from a large trial which showed the gel failed to protect women from acquiring HIV. The study followed over 9,000 women in South Africa, Uganda, Zambia and Tanzania. The study started with 3 arms- two different doses, or concentrations of PRO 20000 and a placebo arm. One of the PRO 20000 arms was closed early by the study's Data Safety and Monitoring Board- an independent group of scientists who review unblended results from an ongoing trial to protect the safety of the participants.

The development of an effective and safe microbicide is among the most important fronts in the fight against HIV, particularly- though not by any means exclusively- for women. These results are the latest setback in this much-fraught search. Several once-promising candidates have proved either ineffective or even harmful. The focus of microbicide research will now be firmly on gels or rings that contain anti-HIV drugs. PRO 20000 was designed to attach to HIV before it could invade cells. One of the lead investigators described it as, 'a large sugary molecule with a charge on it.' Several anti-retroviral (ARV) microbicides are under investigation, including one containing maraviroc (the compound in Selzentry), one with tenofovir (Viread) and another with an NNRTI called daprivirine or TMC120.

To end on some good news, a report out of Switzerland found that the widespread availability of  ARVs led to a dramatic drop in suicide among HIV positive Swiss. This is not terribly surprising, but does lead to a couple of interesting questions. The two I wonder about is the impact of HIV on the brain and the role of hope in living successfully with HIV.

On the brain: We know full well that HIV replicates in the brain. We know that cognitive function might be affected by HIV, and we have some limited data on the affect of HIV drugs on the brain. Teasing out whether or not HIV replication itself leads to emotional changes would be quite tricky I imagine. Nonetheless it is an interesting question, especially as it might relate to risk of suicide.

On hope: I have long thought, and often said that one of the most important factors in long term survival with HIV is a belief that one can live a long, healthy life with HIV. This idea can and is overplayed and warped by people who take it to mean that our health outcomes are mostly or entirely determined by how happy we are (Louise Hay are you listening?!) Not so. But hope- the emotional sense of optimism and wellbeing- can influence our health in obvious and subtle ways. Making the daily decision to take our meds, having an active and fulfilling social life, being involved in the world around you- these are things that make us healthier and are often only possible when one has hope. Depression, social anxiety, isolation, self-harm- these are things that often spring from a sense of hopelessness- and lead to poor health.

So mourn the loss of Dennis, save the Koalas from KIDS, onward in the fight for a microbicide and keep hope alive.

Warning: No HIV Content Below:

A dear, dear friend of mine Carol posted this to me on Facebook recently: 'One day, Paul Dalton, we will have to have a conversation about how you reconcile your anti-capitalist tendencies with your love for Major League Baseball. I am curious about this dichotomy.'  This is a common, and totally understandable question for the people I run with, who don't exactly embrace the world of sports, particularly the big money, professional ones.

I was actually thinking about this last night while trying to get to sleep. While baseball is far and away my sport of choice, I follow football, hockey and college basketball as well. Part of the answer is I simply enjoy the organic drama of sport and the physicality and athleticism.

I generally fight against disparity- economic, social, political, gender- you name it- my politics are all about leveling the playing field, sharing the wealth if you will. So, how is it I root for the Yankees, the greatest symbol of disparity in sports? The Yankees are the richest, most successful franchise in major US sports. They have the most money, they spend the most money and they win the most. They had a payroll last year topping $200 million dollars, and christened their $1.5 billion stadium with their 27^th World Series title. The Saint Louis Cardinals are second with 10.

Sports for me are a way of connecting with myself as a child. The Yankees of the 1970s were among the first things outside of my immediate life (family, school) that I really cared about as a kid. As a 10 year old, the 1977 Yankees became the center of my life for the summer. Whenever possible, I would listen to games on the radio, and I never missed the rare opportunity to see them on TV.

As I grew older, I came to care about many thing outside of myself, many of them much more important than sports.  The nuclear arms race, war, gender equality, homelessness, Apartheid- these things began to animate me, to drive me. Music and politics became the focus of my life. I found Punk- a milieu where music and activism sat well, if not always comfortably together. Sports and I drifted apart.

The mid 90s Yankees brought be back to sports. Following their rise from over a decade of futility to dominance was beyond compelling. These Yankees of Derek Jeter, Andy Pettitte, Jorge Posada and Joe Torre were an easy team to love- talented, successful and home grown.

Watching a Yankees game- or a Syracuse Orange basketball game, an Alabama Crimson Tide football game or a Buffalo Sabres hockey game, helps me connect with my most child-like self, to tap in to that part of me that never grew up. I know that is pretty pop-psychology/self-help-ish, but so bit it.

The original question though was how do I reconcile my antipathy to capitalism with my love for Major League Baseball and, I would add the Yankees. Mostly it boils down to 1) I don't really care about economic inequality in sports and 2) I think baseball is economically the fairest major sport. Major League Baseball has a very strong players union- the strongest in sports. Efforts in other sports to 'level the playing field' have resulted in less competitive balance, more money for the owners and less security for the players.

I abhor inequality. I just can't bring myself to care about it in the context of professional sports. I am much more concerned that the top 10% of American families own about 70% of the wealth, than I am that the Yankees payroll was over 5 times higher than the lowest. Sure I think Alex Rodriguez is way over paid, but nothing compared to Warren Buffett or any of the folks who ran Lehman Brothers into the ground. The inequality I care about is the kind that leads to people with HIV not having access to life saving drugs, not the kind that leads the Minnesota Twins to trade or lose their best players.

I won't go in to the economics of baseball and how they do, or do not directly affect the fairness of the game. It is complex and frankly a bit beyond me. Also this post is already way too long.

So, in short how do I reconcile my love of Major League Baseball with my anti-capitalist politics? I don't try to. Baseball is my refuge from important things, the space in which I let myself simply enjoy the action- not worrying about the problems of the world. Is there a contradiction here? Probably, yes- but it is one I am comfortable with. 

Interesting juxtaposition in today's New York Times about the perils of politicizing science. While I believe that virtually nothing can be exempted from political meaning and influence, these two quite different cases illustrate the peril of allowing political agendas to drive scientific endeavors.

The first article is about South African President Jacob Zuma announcing new measures to combat HIV in its epicenter. The actions themselves would be less noteworthy (but still laudable), if not for the deadly dance with denialism of South Africa's previous President Thabo Mbeki.

Mbeki embraced the thinking of the disparate and desperate group we call AIDS denialists. This club-led by folks like Nobel Laureate gone soft in the head Peter Duesberg, snake oil salesman Matthias Rath and criminally negligent child-killer Christina Maggiorre- don't really believe anything per se- at least not anything they can all agree on. Instead they are bound by an unshakable disbelief that HIV causes AIDS.

I have written about AIDS denialism before and don't have time to go in to detail here about the mental gymnastics necessary to hold such a belief today. Mbeki is a special case though, because he led the country most impacted by HIV/AIDS for almost a decade and his dithering, obstructionism and denial caused over 300,000 deaths, including some 35,000 babies. Some in South Africa are calling for him to be charged with murder or even genocide.

On the same page is an article about climatologist Phil Jones resigning from his position at a UK university, in the wake of scandal over the suppression of minority opinion on the question of climate change. Hacked emails apparently show Jones and others conspiring, or thinking about conspiring to keep the work of scientists who question the majority opinions about global warming out of journals, to skew and hide data when it didn't agree with their position and to 'overstate' the data in support of their position.

On the surface these two stories seem at odds. The climate scientists are accused of suppressing minority opinion, while Mbeki embraced it. But really they are about the same thing- allowing political or really any pre-determined agenda to drive science. In the case of Mbeki, he embraced a position that was attractive to him- maybe because it harmonized with aspects of his political world view, maybe because he realized how daunting the reality of HIV in South Africa was and couldn't wrap his head around dealing with it. In the case of Jones, it sounds likely that he and others allowed their sense of urgency over the threat of climate change to justify their efforts to marginalize their opponents and overstate the data in support of their position.

The strength of science is that it should have no agenda. Scientists of course are human and do have agendas- political, professional, personal- and the process of peer review and publication seeks to account for that. Science is not a set of beliefs or stories- it is a methodology, a way of uncovering what is hidden. Put another way- science is not so much about discovering what is, as showing what isn't. The greatest accomplishment of modern medicine is not germ theory, but the discrediting of once widely held beliefs like miasmas and humors.

One needs to go where the truth is- where the data tells it is. In the case of Mbeki and his cohorts, they had to reject out of hand the crushing weight of the accumulated data showing HIV to be the cause of AIDS- and instead embrace a hodgepodge of crackpot ideas, paranoia and gaps in understanding to make their case. For Jones it appears there is a lack of trust in the process, a fear that an honest hearing of the facts wouldn't support their idea, or might fuel their opponent's efforts to sew doubt.

Let the truth win out. Let the data be your guide. 

Happy World AIDS Day just doesn't sound right does it?

Haven't blogged in a while. Why? No real reason- just a bit of ennui plus inertia. But today is our day, so here is what I am thinking today.

The new Guidelines were released this morning. I am a community member on the panel that writes the recommendations, and this update includes some important changes. Just so we are clear- I do not speak for the Guidelines panel- these are just my thoughts.  

One major change is the 'when to start' language. Specifically starting treatment with a CD4 count between 350 and 500 in now recommended. There was significant difference of opinion on how to characterize the strength of evidence for this- most saying the evidence is strong, but a significant minority seeing the evidence as more moderate. Treatment with a CD4 count above 500 is talked about- basically stating that the panel was evenly split between those basically supporting treating virtually everyone with HIV and those who feel that the evidence is just not strong enough and that treatment could be initiated, but should not be recommended.

My thinking? I have come to believe that, in most cases treatment is better than no treatment. The panel bases it's guidelines on the available evidence- which is where these questions become sticky. There simply isn't a large, prospective, randomized, controlled clinical trail answering the 'when to start' question. Lacking this gold standard means we have to look at other forms of research- non-randomized trials, retrospective analyses, cohorts and so on- to build the recommendations.

To me the data, while not straight forward, are convincing. Most of the studies done in the past 5 years or so show strong benefit of treatment, in most cases. While there is no debate that HIV drugs can cause harm, it is increasingly clear that the untreated virus wreaks much havoc, beyond CD4 counts. Looking at heart disease, liver disease, kidney disease, cognitive function, aging- whatever measure you look at, people on meds seem to do better than those not on treatment.

The other major changes are in the 'what to start' section where Kaletra was 'demoted' to alternative (while still preferred for pregnant women), and Isentress was added to the 'preferred' list. This boils down to side effects- most widely used HIV drugs work well now in terms of reducing viral load- the real differences (for the most part) are around toxicity. Simply put, Kaletra's effect on lipids (fats) and some data suggesting it might increase the risk of heart attack, dragged it down to alternative.

Adding Isentress to the 'preferred' first line group made sense to me. The STARTMRK data show it works quite well as part of initial therapy. The real question for me is more philosophical- given how well this drug works in later treatment and with no back up integrase drug in the foreseeable future, is it wise to use this drug as a first option. In my opinion- probably not. But that is just my opinion- the data support its use this way, and so I supported adding it to the list.